In 2003, the Government of Tanzania, the Swiss Agency for Development and Cooperation (SDC) and the Swiss TPH partnered to develop an ITN cell within the National Malaria Control Programme (NMCP) to put the NATNETS strategy into practice. Swiss TPH through a project called NETCELL provided experienced staff and technical support to this cell, and SDC provided funding. The ITN cell became responsible, on behalf of the Tanzanian Government, to coordinate NATNETS and the programme’s overall management and fundraising. In 2011 the responsibility for managing the ITN Cell was reverted to MoHSW staff with continued technical support from NETCELL. The Project is currently in its fifth and final phase and runs from 1 April 2013 until 30 March 2018.

LLIN Strategy 2014 - 2020

As the two massive distribution campaigns of free LLINs have been completed, and a third one under preparation, the country needs to embark on more sustainable “keep-up” strategies for maintaining the current high level of ITN use. A new LLIN strategy is currently under development which builds on the successes of previous years and the strong culture of net use in the population. Stratification in terms of LLIN delivery mechanisms will continue to be developed in line with RBM recommendations1, (i.e., a combination of campaign [catch-up] and continuous distribution [keep-up] systems of distribution).

A key priority for maintaining universal coverage will be to establish systems to monitor coverage and variations in the rate of loss so that the rate of the expected LLIN input can be adjusted to balance this loss. When resources are constrained, LLINs will be targeted to risk groups, especially young children and pregnant women in high transmission areas. The objective of the new LLIN strategy is to ensure universal access of the population to LLINs in all transmission settings and control stages. Four strategic interventions are proposed to reach this objective.

Strategic Interventions

1. Implement a mass replacement campaign to bring LLIN coverage from 67% in 2012 up to 80% in 2020

Most of the LLINs distributed during the two past mass campaigns (in 2009 and 2010–2011) will be over three years old by 2014 and will have passed their effective lifetime. Household net use throughout the country will likely have dropped below a threshold of 60% as ownership decreases due to the decay of nets. Therefore, as an interim measure prior to rolling out a national continuous distribution mechanism, the MoHSW will implement an LLIN replacement campaign, which will provide one LLIN for every two people living in a household. The campaign will be rolled out to all households in the country, with the exception of the Southern Zone where the ongoing School Net Programme will continue.

2. Implement continuous distribution mechanisms to keep up coverage with 8 million LLIN distributed in 2020

Approximately 7 million new nets are needed annually in Tanzania, increasing to 8 million by 2020, to maintain LLIN coverage at 80%. Therefore a continuous distribution mechanism will be implemented nationally, starting within one year after the mass replacement campaign. A combination of a school-based distribution (i.e., a school net program, together with the existing Tanzania National Voucher Scheme) will provide enough nets annually to sustain universal coverage.

The combined approach of SNP and TNVS is expected to reach 85% of the Tanzanian population. This model has the lowest cost per net delivered and the least number of excess nets. It also ensures continuity across geographical areas and over time. The strength of the model lays in the combination of the two distribution approaches, with the TNVS providing approximately 30% of the LLIN to pregnant women and children under 5 years, a key target group that cannot be reached through school-distribution.

The continuous distribution approach and the individual mechanisms (i.e., SNP and TNVS) will be regularly monitored and evaluated. When and if necessary, the model will be adapted and revised; e.g. by enabling these individuals to register with the schools for a free net. Verification of these households can be done by the community structures.

3. Implement targeted distribution to vulnerable groups to bring the coverage for infants and pregnant women from 71% and 73% in 2012 respectively to 85% by 2020

A health facility-based distribution mechanism needs to be implemented in conjunction with the SNP to ensure that the most vulnerable groups (children and pregnant women) are continuously protected and have access to LLINs when they need them. The TNVS is a public-private partnership that has been implemented on a national scale since 2004. The aim is to continue the Voucher Scheme in all districts, funding permitted.

To address the supply and demand side constraints of the programme, the TNVS model will be reviewed in the coming strategic planning period. Key issues include ensuring that all public and private health facilities in the country participate in the programme, recruiting more retail outlets, and preventing voucher and LLIN stock outs. Further analysis of voucher uptake will be also assessed, including ability-to-pay, particularly amongst the lowest socio-economic quintiles in the rural areas. The review will consider a stratified approach, especially in remote areas that are ecologically unsuitable for malaria transmission and where voucher uptake is low.

4. Create an enabling environment to revive the commercial market for ITNs and LLINs to reach 3 million ITNs/LLINs sold commercially in 2020

In the long-term, the most economically sustainable approach to continuous LLIN distribution is the re-establishment of a viable commercial market for insecticide treated nets. Further studies will be undertaken to determine the realistic future potential commercial market in different areas. The analysis will include consumer behaviour in terms of ability and willingness to pay (specifically in light of the availability of free or highly subsidized LLINs) as well as access of hard-to-reach and vulnerable populations to LLINs and recommendations at to most effective methods to reaching the poor. The aim is to increase the number of LLIN brands sold on the commercial market, and to expand the range of size, shape and colour of nets to provide more choice to customers.

Approximately 1.2 million to 1.5 million untreated polyester nets are currently sold on the commercial market in Tanzania annually, without any intervention from programmes. NMCP will assess whether it is feasible to introduce treatment at factory level and/or reintroduce retreatment kits to make these nets into ITNs and help maintain the ITN coverage.